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July 2015 - Volume 94 - Issue 27
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Research Article: Observational Study
Obesity Among HIV-Infected Adults Receiving Medical Care in the United States
Data From the Cross-Sectional Medical Monitoring Project and National Health and Nutrition Examination Survey
Thompson-Paul, Angela M. PhD, MSPH; Wei, Stanley C. MD, MPH; Mattson, Christine L. PhD; Robertson, McKaylee MPH; Hernandez-Romieu, Alfonso C. MD, MPH; Bell, Tanvir K. MD; Skarbinski, Jacek MD
Editor(s): Chaurasia., Akhilanand
From Division of HIV/AIDS Prevention (AMTP, SCW, CLM, MKR, ACHR, JS); Epidemic Intelligence Service, Centers for Disease Control and Prevention, Atlanta, Georgia (AMTP); United States Public Health Service, Rockville, Maryland (AMTP, SCW); Oak Ridge Institute for Science and Education (MKR); Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, Georgia (ACHR); and Department of Internal Medicine, Division of Infectious Diseases, University of Texas Medical School at Houston, Houston, Texas, USA (TKB).
Correspondence: Jacek Skarbinski, Division of HIV/AIDS Prevention, CDC/OID/NCHHSTP, 1600 Clifton Road NE. Mail-Stop E-46, Atlanta, GA 30329, USA (e-mail: [email protected]).
Abbreviations: ART = antiretroviral therapy, BMI = body mass index, CD4 = CD4+ T-lymphocyte cell, CDC = Centers for Disease Control and Prevention, CI = confidence interval, CVD = cardiovascular disease, HIV = human immunodeficiency virus, MMP = Medical Monitoring Project, NHANES = National Health and Nutrition Examination Survey, PR = prevalence ratio, SE = standard error, SPR = standardized prevalence ratio.
The findings and conclusions in this report are those of the authors and do not necessarily represent the views of the CDC.
The CDC provides funds to all states and the District of Columbia, through a Cooperative Agreement (PS09-937), to conduct the HIV surveillance used in this study and to selected areas to conduct the MMP, and provides technical assistance to all funded areas.
AMTP, SCW, MKR, and JS had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept, design, and conduct; and acquisition of data: AMTP, SCW, CLM, and JS. Analysis and interpretation of data: AMTP, SCW, CLM, MKR, ACHR, and JS. Drafting of the manuscript: AMTP, SCW, CLM, and JS. Critical revision of the manuscript for important intellectual content: All authors. Statistical analysis: AMTP, SCW, ACHR, and JS. Obtained funding: JS. Administrative, technical, and material support: CLM, SCW, and JS. Study supervision: SCW, and JS. The CDC reviewed and approved final submission.
The authors have no conflicts of interest to disclose.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Website (www.md-journal.com).
This is an open access article distributed under the Creative Commons Attribution License 4.0, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. http://creativecommons.org/licenses/by/4.0
Received May 1, 2015
Received in revised form June 3, 2015
Accepted June 4, 2015
Medicine: July 2015 - Volume 94 - Issue 27 - p e1081
doi: 10.1097/MD.0000000000001081
Our objective was to compare obesity prevalence among human immunodeficiency virus (HIV)-infected adults receiving care and the U.S. general population and identify obesity correlates among HIV-infected men and women.
Cross-sectional data was collected in 2009 to 2010 from 2 nationally representative surveys: Medical Monitoring Project (MMP) and National Health and Nutrition Examination Survey (NHANES).
Weighted prevalence estimates of obesity, defined as body mass index ≥30.0 kg/m2, were compared using prevalence ratios (PR, 95% confidence interval [CI]). Correlates of obesity in HIV-infected adults were examined using multivariable logistic regression.
Demographic characteristics of the 4006 HIV-infected adults in MMP differed from the 5657 adults from the general U.S. population in NHANES, including more men (73.2% in MMP versus 49.4% in NHANES, respectively), black or African Americans (41.5% versus 11.6%), persons with annual incomes <$20,000 (64.5% versus 21.9%), and homosexuals or bisexuals (50.9% versus 3.9%). HIV-infected men were less likely to be obese (PR 0.5, CI 0.5–0.6) and HIV-infected women were more likely to be obese (PR1.2, CI 1.1–1.3) compared with men and women in the general population, respectively. Among HIV-infected women, younger age was associated with obesity (<40 versus >60 years). Among HIV-infected men, correlates of obesity included black or African American race/ethnicity, annual income >$20,000 and <$50,000, heterosexual orientation, and geometric mean CD4+ T-lymphocyte cell count >200 cells/μL.
Obesity is common, affecting 2 in 5 HIV-infected women and 1 in 5 HIV-infected men. Correlates of obesity differ for HIV-infected men and women; therefore, different strategies may be needed for the prevention and treatment.
Since the introduction of combination antiretroviral therapy (ART) in the mid-1990s, human immunodeficiency virus (HIV) associated morbidity and mortality has dramatically declined.1,2 Life expectancy of HIV-infected adults receiving ART has increased and is approaching that of the general population.3–6 As the population receiving ART ages and lives longer with HIV infection, chronic and age-related conditions are increasingly prevalent and contribute substantially to overall morbidity and mortality.7–11 Less than one-quarter of deaths among HIV-infected persons receiving care are due to AIDS whereas up to half are due to noninfectious causes such as cardiovascular disease (CVD), non-AIDS-related malignancies, and renal disease.8,9
Obesity is an independent-risk factor for CVD and obese individuals in the general U.S. population are nearly twice as likely to experience CVD, even after adjustment for other traditional-risk factors.12 For health care providers and patients, it is important to prevent and treat obesity, as there is an increase in risk for additional comorbid conditions and mortality in persons with body mass index (BMI) >30 kg/m2; for HIV-infected obese persons, this risk may be even greater than in the general population. Several estimates of the prevalence of obesity among HIV-infected adults have been reported in the literature, ranging from 9% among HIV-infected men in the military13 to 33% among HIV-infected women in Alabama14 (eTable 1, https://links.lww.com/MD/A327); however, these estimates have been derived from small studies or subpopulations with limited generalizability rather than from large, national, and population-based studies.7,11,13–24
Estimating the prevalence and correlates of obesity is a first step in identifying important comorbid conditions that affect HIV-infected persons and may contribute to increased mortality from non-AIDS-defining conditions. The objectives of this analysis were three-fold: to estimate the prevalence of obesity among HIV-infected individuals receiving medical care at HIV outpatient clinics using nationally representative data; to compare obesity prevalence in HIV-infected individuals receiving medical care at HIV outpatient clinics to that in the general population; and to identify factors associated with obesity in HIV-infected men and women receiving medical care at HIV outpatient clinics.
We describe the prevalence of obesity in a nationally representative sample of HIV-infected adults receiving care using population-based data from the 2009 data collection cycle of the Medical Monitoring Project (MMP)25–28 and compare it to the prevalence of obesity in a nationally representative sample of the U.S. population from the 2009 to 2010 National Health and Nutrition Examination Survey (NHANES).29,30
Medical Monitoring Project (MMP)
MMP is an HIV surveillance system designed to produce nationally representative estimates of behavioral and clinical characteristics of HIV-infected adults receiving medical care from HIV outpatient facilities in the United States.25–28 MMP is funded by the Centers for Disease Control and Prevention (CDC). MMP methods, including weighting procedures, have been described in detail elsewhere.25–28 Briefly, MMP has a cross-sectional design in which U.S. states and territories were sampled first, then eligible facilities within each state were selected, and finally, eligible individuals were selected from facilities. Eligible facilities were those that provided outpatient HIV care, defined as the treatment and management of HIV infection, including monitoring CD4+ T-lymphocyte cell (CD4) count and HIV viral load tests, or the prescription of ART. For the 2009 data collection cycle, eligible individuals were HIV-infected adults, aged 18 years or older, receiving medical care in participating facilities in 16 states and Puerto Rico, between January and April 2009. Data from MMP were weighted to produce nationally representative estimates of all HIV-infected adults receiving care in the United States. In the 2009 data collection cycle, between June 2009 and May 2010, 100% of sampled states and territories participated, 461 out of 603 sampled facilities participated (facility response rate, 76%), and 4217 of 9338 sampled persons completed an interview and had their medical records abstracted (patient-level response rate, 51%). Women who reported having been pregnant in the prior 12 months (n = 47) and persons missing weight data in their medical records (n = 164) were excluded from analysis (Figure 1). We analyzed data on 4006 participants and weighted the data to represent 399,062 HIV-infected adults in HIV medical care in the United States during January to April 2009.
Flow diagram of participants included in this analysis of obesity among HIV-infected adults receiving medical care and adults in the general population of the United States. *Body mass index (BMI) directly calculated as weight in kilograms divided by height in meters squared (kg/m2). **BMI category inferred using available weight data and standard distribution of heights for age and sex in United States.
Face-to-face interviews were conducted to collect information on 11 behavioral and clinical domains, characteristics including gender at birth, race, educational attainment, annual income, sexual orientation, and time since HIV diagnosis were self-reported during interviews. Data on weight, height, stage of disease, prescription of ART, and viral suppression were collected through abstraction of medical records for the year prior to the date of interview.
In accordance with the federal human subjects protection regulations at 45 Code of Federal Regulations 46.101c and 46.102d 13 and with the Guidelines for Defining Public Health Research and Public Health Non-Research,31,32 MMP was determined to be a non-research, public health surveillance activity used for disease control program or policy purposes. As such, MMP is not subject to review by a federal investigational review board and received approval for its protocol from CDC officials who were not involved with MMP implementation.31 Participating states or territories and facilities obtained local institutional review board approval to conduct MMP if required locally.
National Health and Nutrition Examination Survey (NHANES)
NHANES, conducted by the National Center for Health Statistics, CDC, is a series of cross-sectional nationally representative health examination surveys designed to assess the health and nutritional status of the civilian, noninstitutionalized U.S. population.29,30 NHANES relies on a complex, multistage probability sampling design to select a representative sample, selecting counties as the primary sampling unit, then a block or group of blocks within the county, then specific households within each block, and finally individuals within each household. Weight and height were measured in a mobile examination center using standardized techniques and equipment. Participants reported demographic information during the family interview, and sexual orientation was reported by the participant using a computer-assisted personal interviewing system in the mobile examination center. From 10,537 sampled persons, 10,253 persons had both interview and body measurement data; we excluded from analysis persons who were younger than 18 years of age (n = 4277), pregnant (n = 68), or had missing or invalid weight data (n = 247, Figure 1). Of the NHANES participants included in this analysis, 85% reported having a usual place of health care. NHANES 1999 to 2010 underwent National Center for Health Statistics institutional review board/research ethics review board approval; written informed consent was obtained from the participants.
For MMP and NHANES, distribution of sociodemographic characteristics was summarized using unweighted counts and weighted percentages with 95% confidence intervals (CIs). Factors associated with obesity and common to both surveillance systems included gender, age at the time of interview, race/ethnicity, educational attainment, and sexual orientation.14,33–37 We additionally examined HIV clinical care factors reported to have variable associations with obesity or weight gain in small studies or subpopulations, including years since HIV diagnosis, CD4 count, HIV disease stage per CDC criteria,38 ART prescription, and recent viral suppression (most recent viral load during the past 12 months was undetectable or ≤200 copies/mL).13,14,16,17,23,39
The weighted prevalence and 95% CI of obesity were estimated separately for men and women, because obesity reports on the general population stratify by gender14 and because evidence from other studies indicated that the prevalence of obesity among HIV-infected persons may differ by gender.7,13,14,17,18,20 BMI was calculated as weight in kilograms divided by height in meters squared (kg/m2). Following current recommendations, obesity was defined as a BMI ≥ 30.0 kg/m2.40 When height was missing (Figure 1), BMI category was inferred from recorded weight using the assumption that the heights of respondents fell between the 2.5th and 97.5th percentiles of age and sex-matched members of the U.S. population.41 Participants with missing or invalid weight measurements were excluded from analysis (eTables 2 and 3, https://links.lww.com/MD/A327).
For the characteristics common to both surveys, stratum-specific prevalence ratios (PRs) were summarized with standardized prevalence ratios (SPRs, 95% CI), utilizing the weighted prevalence and corresponding standard error (SE).42 This approach is an extension of the indirect method for calculating age-adjusted standardized mortality ratios, in which the observed mortality rate in a population of interest is compared with an expected one derived from the age-specific mortality rates of a standard population.43
Among HIV-infected men and women receiving care who participated in MMP, we assessed bivariate associations with Rao-Scott X2 tests to identify factors associated with obesity.44 Variables with P ≤ 0.15 in bivariate tests were included in multivariable logistic regression models examining factors independently associated with obesity in HIV-infected men and women. All two-way interactions of significant variables were considered for inclusion; tests for interaction were performed with likelihood ratio tests by comparing 2 nested multivariate models with and without the interaction term, rejecting the null hypothesis with P ≤ 0.05. We used predicted marginal probabilities to calculate the adjusted prevalence of obesity in multivariable logistic models.45 To assess the effect of missing weight data on our results, we conducted sensitivity analyses to examine differences in sociodemographic characteristics between participants who had complete weight and height data (BMI directly calculated), complete weight data only (BMI inferred), and those who were missing weight data (excluded from analysis). We then removed persons with inferred BMI from the analytic dataset and repeated analyses.
All analyses accounted for complex survey designs, weighted analyses were conducted using SAS-callable SUDAAN (RTI International, Research Triangle Park, NC), PROC SURVEYFREQ and PROC RLOGIST, in SAS 9.3 (SAS Institute, Cary, NC) for MMP and NHANES data. SPR calculations were performed in Microsoft Excel 2010 (Microsoft Corporation, Redmond, WA).
Among the 4217 MMP participants with matched interview and medical record data during the 2009 data collection cycle, 4006 (95.0%) had sufficient information for calculation or inference of BMI and were included in the analytic sample (Figure 1). From 9075 persons interviewed and examined in NHANES in the 2009 to 2010 cycle, 5661 (62.4%) met inclusion criteria and had sufficient information for calculation of BMI. As shown in Table 1, the MMP population differed from the NHANES population on a number of demographic factors. Compared to NHANES, MMP included a greater proportion of males (73.2% versus 49.4%), persons aged 40 to 59 years (66.0% versus 39.4%), blacks or African Americans (41.5% versus 11.6%), persons with low income (annual income <$20,000: 64.5% versus 21.9%), and homosexual or bisexual participants (50.9% versus 3.9%). The majority of MMP participants had been diagnosed with HIV for more than 10 years (54.0%), had stage 3 (AIDS, 67.9%), were prescribed ART (83.8%), and had suppressed viral load at their most recent test (72.4%).
Characteristics of HIV-Infected Adults Receiving Medical Care and Adults in the General Population of the United States—Medical Monitoring Project (MMP), 2009 and National Health and Nutrition Examination Survey (NHANES), 2009
Table 2 presents the weighted prevalence (SE), stratum-specific PR, and SPR for obesity in MMP compared with NHANES for men and women. Overall, the prevalence of obesity among HIV-infected adults receiving care, compared to those in the general population was 46% lower in men (PR: 0.54, 95% CI 0.48, 0.61) and 17% higher in women (PR: 1.17, 95% CI: 1.06, 1.30). HIV-infected men receiving care were significantly less likely to be obese compared to men in the general population regardless of age, race/ethnicity, education, income level, or sexual orientation. Among women, SPR for obesity differed by subgroups. HIV-infected women receiving care were more likely to be obese than women in the general US population after standardization for age (SPR: 1.21, 95% CI 1.09, 1.34), or sexual orientation (SPR: 1.25, 95% CI 1.13, 1.40); but, less likely to be obese in prevalence estimates standardized by race/ethnicity (SPR: 0.87, 95% CI 0.78, 0.98).
Relative and Standardized Prevalence of Obesity by Gender and 5 Demographic Characteristics – Medical Monitoring Project (MMP), 2009 and National Health and Nutrition Examination Survey (NHANES), 2009–2010
Correlates of obesity differed for HIV-infected men (Table 3) and women (Table 4). In multivariable models, race/ethnicity, income, sexual orientation, and CD4 count were significant correlates of obesity in HIV-infected men receiving medical care; those with annual income under $50,000 but over $20,000, heterosexual men, and those with CD4 count greater than 200 cells/μL were more likely to be obese. Compared to black or African American men, Hispanic, or Latino HIV-infected men receiving medical care were less likely to be obese. Among women, only age remained a significant correlate of obesity after controlling for factors significant in bivariate models; HIV-infected women receiving medical care aged less than 40 years were more likely to be obese compared to those aged 60 years or more (P = 0.04). We found no statistically significant two-way interactions; therefore, they were not reported.
Bivariate and Multivariable Associations of Sociodemographic Characteristics and Obesity in HIV-Infected Men in Care in the United States — Medical Monitoring Project (MMP) 2009
Bivariate and Multivariable Associations of Sociodemographic Characteristics and Obesity in HIV-Infected Women in Care in the United States — Medical Monitoring Project (MMP) 2009
Among MMP participants, there were no differences in sociodemographic characteristics between individuals who had complete weight and height data (BMI directly calculated) and complete weight data only (inferred BMI). Compared to persons with complete weight and height data, those who were missing weight data (excluded from analysis) included significantly more women, more persons under the age of 40 years, and a higher proportion had detectable viral loads (eTable 4, https://links.lww.com/MD/A327). Among NHANES participants, few comparisons could be made due to small numbers of persons with complete weight data only and missing data among those who were excluded from the analysis (eTable 5, https://links.lww.com/MD/A327). In sensitivity analyses, the removal of persons with inferred BMI did not result in any substantial changes in findings; therefore, these results are not presented.
In this report, we present the first nationally representative estimates of obesity among HIV-infected adults receiving care in the United States. Similar to some previous studies,7,19 we found that 19% of HIV-infected men in medical care were obese and were approximately half as likely to be obese as men in the general U.S. population. However, our finding that 42% of HIV-infected women in medical care were obese is higher than previous estimates of obesity among HIV-infected women.7,13,14,16–18,20,21
Although obesity is nearly ubiquitous, affecting 1 in 3 adults in the general U.S. population, important differences in prevalence were observed by gender, race/ethnicity, and age, with the greatest prevalence among women, racial and ethnic minorities, and persons with low socioeconomic status.46 Among HIV-infected persons receiving medical care, sexual orientation, and HIV-related factors were associated with obesity. Although the prevalence of obesity was similar for men and women in the general population, HIV-infected women receiving care were twice as likely to be obese as HIV-infected men receiving care. Black or African American women in the general and HIV-infected populations have a higher prevalence of obesity than White/Caucasian or Hispanic/Latina women. Although obesity was more common among HIV-infected women, after standardization for race, HIV-infected women were less likely to be obese than women in the general population, suggesting that the distribution of race and obesity differed among HIV-infected women compared with the general population. The association between age and obesity prevalence is inverse in HIV-infected women; whereas in the general population the highest prevalence of obesity is among those 60 years and older, in HIV-infected women the highest prevalence is among those younger than 40 years. The lower prevalence of obesity among HIV-infected women aged 60 years and older may be due to a survivor bias or cohort effect.
Similar to other studies,14,47 we found sexual orientation to be an important correlate of obesity among HIV-infected men: heterosexual men were more likely to be obese than homosexual or bisexual men, even after controlling for sociodemographic and HIV-related factors. Contrary to studies which reported that lesbian or bisexual women were more likely to be obese,47 we found that HIV-infected heterosexual women were more likely to be obese than HIV-infected homosexual women or women in the general population. Although obesity prevalence differed by sexual orientation among HIV-infected women, sexual orientation was not a significant correlate of obesity among HIV-infected in this analysis, perhaps due to small sample size.
With effective treatment and control of HIV infection, HIV-infected persons can live longer and experience fewer AIDS-related complications.3–11,48 Obel et al48 recently reported that among those with no comorbidity or substance abuse, persons with optimally treated HIV infection were not at substantially increased risk of mortality compared with the general population. However, risk of myocardial infarction may be increased by 50% or more among HIV-infected persons compared with uninfected persons.15 Compared to HIV-infected persons with no risk factors or comorbid conditions, mortality risk may be increased by nearly 40% among HIV-infected persons with HIV-risk factors and 70% among HIV-infected persons with comorbid conditions.48 Non-AIDS-related comorbid conditions such as CVD, non-AIDS-related cancers, kidney disease, diabetes, hypertension, and dyslipidemia have increased among persons living with HIV since the introduction of highly active ART in the mid-1990s when the number of AIDS-related deaths began to decline.7,9 Although HIV- and/or ART-associated factors, such as chronic inflammation and immune activation, may contribute to increased risk for CVD49 among HIV-infected persons, traditional CVD-risk factors such as obesity or smoking may confer additional risk for HIV-infected persons. HIV-infected persons are twice as likely to smoke as the general population,50 and HIV-infected smokers may be more than twice as likely to experience a CVD event. Furthermore, HIV-infected smokers have reduced life expectancy compared with former or never smokers.51 Because obese individuals are at increased risk for CVD morbidity and mortality,12 obese HIV-infected individuals in care may be at further elevated risk due to the compounded effects of HIV infection, ART use, and increased prevalence of CVD-risk factors such as smoking.
In studies enrolling HIV-infected patients in the early to mid-1990s before ART, excess weight was associated with slower HIV progression;16,52 however, since the implementation of ART, that relationship may have changed. Although we found that CD4 count >200 cells/μL was associated with obesity in men and a recent cross-sectional analysis by Blashill et al22 found that a 1-unit increase in BMI was associated with an 8.7-unit increase in CD4 count, prospective studies have indicated that CD4 count among obese men did not significantly differ from that of normal weight men at 14 months22 and that obese HIV-infected persons gained significantly fewer CD4 cells compared to normal weight and overweight persons 4 years after ART initiation.53 This evidence does not indicate that excess weight leads to improvements in HIV infection or outcomes overtime, it may simply be that more individuals are obese at time of infection or gain weight after initiating ART.22,53
For HIV-infected individuals in care and with well-controlled infection, a complementary strategy to address risk factors such as obesity is needed. Guidelines for the Management of Overweight and Obesity54 advise calculating BMI and measuring waist circumference at least annually for patients in the general population in addition to counseling for health goals, including weight loss, physical activity, and dietary modification. In HIV-infected populations, aerobic and resistance exercise have been shown to produce positive benefits for multiple outcomes, including body composition, functional capacity, muscular strength, and cholesterol.55 Although the effect of exercise and physical activity on immune function has not been determined, exercise has been shown to be safe and beneficial in HIV-infected adults. The guidelines for the general population could be followed until evidence accumulates to support guidelines specific to an HIV-infected population.
This study has several limitations. First, temporal associations cannot be established since MMP is cross-sectional. Also MMP had lower than optimal response rates, but data were weighted to adjust for nonresponse. Empirical research indicates that low response rates are not necessarily indicative of nonresponse bias, particularly when probabilistic samples are drawn from rigorously constructed sampling frames.56 Although we were able to stratify our prevalence estimates by gender and standardize by one variable at a time, we were unable to standardize by multiple factors simultaneously, which might have aided interpretation of findings. Weight and height were abstracted from medical records across many different medical clinics in MMP and a standardized protocol for height and weight measurement was not used. Approximately 5% of MMP participants had no weight data and were excluded from the analysis. For those included in the analysis, nearly 21% were missing height data and BMI was inferred based on most likely BMI category according to recorded weight. Although some misclassification may have occurred, sensitivity analyses excluding persons with inferred BMI did not change the findings. Additionally, there were few differences in sociodemographic characteristics for participants who had complete weight and height data (BMI directly calculated), complete weight data only (inferred BMI), and those who were missing weight data (excluded from analysis). Physical activity and diet composition are associated with body composition and weight,18,33,55,57 but are not available in MMP; therefore, we were not able to assess their association with obesity in these analyses.
In this analysis, we examined factors traditionally associated with obesity such as age, race/ethnicity, education, and income. We also considered sexual orientation, time since HIV diagnosis, HIV disease stage, current ART use, and current viral suppression. To our knowledge, this is the only nationally representative study examining obesity prevalence in an HIV-infected population receiving care.
In conclusion, we found that, HIV-infected men receiving medical care at HIV outpatient clinics were about half as likely to be obese but HIV-infected women receiving medical care at HIV outpatient clinics may be more likely to be obese, compared respectively to men and women in the general U.S. population. It is important to note that the prevalence of obesity in HIV-infected women was more than twice that of HIV-infected men. As ART becomes increasingly effective and more easily tolerated, achieving viral suppression is only the first step to ensuring long-term health for HIV-infected patients. Correlates of obesity differ for HIV-infected men and women; therefore, different strategies may be needed for obesity prevention and treatment to reduce morbidity and mortality from adverse long-term outcomes such as CVD.
The authors thank all MMP and NHANES participants and staff members for their time and efforts; also thank Dr. Emma Frazier for MMP data analysis support.
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Oak Park, CA / Tengchong, China – BADWATER®, the world's toughest brand, is pleased to announce the inaugural Mt. Gaoligong Ultra in Tengchong, Yunnan Province, China on November 18-19 of this year. The 104-mile (168km) challenge – with a 36-hour time limit and 29,000 feet (8800m) of elevation gain – is a mountain trail race through history and time.
As befits anything that Badwater is developing and backing, the Mt. Gaoligong Ultra is extremely difficult, with well over 29,000 feet (8800m) of cumulative elevation gain, and a corresponding loss of more than 29,000 feet. It will be held primarily on mountain trails, including single track, double track, jeep roads, and some cobblestone paths. The start line will be at the Yin and Yang Gates in WenZhi-GuangChang Square in Tenchong – allowing the racers to balance their energies as they embark upon this epic challenge – but quickly disappears into the Mt. Gaoligong National Park and mountain range in all its green grandeur covered in trees, bamboo, ferns, and the occasional rice paddy.
Sections of the route traverse the 2400-year-old Southern Silk Road, while the Stillwell Road, a critical supply line built by the Americans during World War II, is also part of the race route. (Americans are particularly appreciated in Tengchong, in part because of the Stillwell Road, and also because the Flying Tigers – American pilots who volunteered to fly for the Chinese during WWII – were based here. (A large sculpture commemorates them outside the Tengchong Airport.) The finish line will be in 600-year-old HeShun Town, the ancient, cobblestone part of Tengchong, providing a historic and exhilarating final few miles for the racers as they complete their historic tour.
The race will be fully supported, with a marked trail, 14 fully stocked aid stations, drop bag service, and more; personal support crews are neither necessary nor encouraged due to the remoteness of the route. Though the main event will be the full 104-mile route, a 77-mile (124km) "short cut" route will be offered mid-race for those not on schedule to finish the entire route within the 36-hour time limit.
Registration for the event is already open, and many well-known Badwater race veterans have already registered. These include Americans Bob Becker, Catra Corbett, Jimmy Dean Freeman, Jared Fetterolf, Joshua Holmes, Andrea Kooiman, Greg Pressler, Ray Sanchez, and Danny Westergaard, plus Luigi Dessy of Puerto Rico, Mick Thwaites of Australia, Dan Lawson of the United Kingdom, Mauro Chasilew of Brazil, Stacey Shand of Canada, Breze Sharma of India, and Hiroyuki Nishimura of Japan.
This new race is not a Badwater® race, per se, but it is a "Badwater Presents" event which Chris Kostman, the Badwater Race Director, is helping to develop and for which he serves as co-race director. Kostman's Chinese partners, XingZhi Yunnan Co. Ltd, are absolute professionals and extremely enthusiastic to host a world-class event this November, and annually thereafter. Kostman's Chinese co-race director, Lin Ma, is rock solid and Kostman's nickname for him is "Mr. Cool." Even though his English is minimal and Kostman's Chinese is even more non-existent, they both speak the same language when it comes to developing and hosting incredible, life-changing sporting events. Another of the principals from XingZhi, Margaret King, recently attended the STYR Labs Badwater 135, which Kostman directs. She and her colleagues work for XingZhi, a China-wide event production company helmed by Xiangdong (Ben) Qu, with over a decade of experience hosting scores of multi-day endurance events with up to 2000 entrants. All their events emphasize the crossroads between sport, culture, and tourism.
Hired as a consultant because of this 32 years of developing world-class – and world-famous – ultra events, Kostman spent eight days in Tengchong in June consulting on every aspect of the race, from routing to start line and finish line, trail marking, aid stations, medical support, communications, marketing, and more. Said Kostman, "I literally spent a full week teaching 'the Badwater Way' of creating, hosting, directing, managing, and marketing events. Fourteen to eighteen people shadowed my every move and took about a hundred pages of notes! On top of that, I was absolutely blown away by the entire route, the historic setting, and even more so by my Chinese partners!" Since June, Kostman and his Chinese colleagues have been having regular WeChat video conferences to work together to develop the race. In November, Kostman will be spend a full month in China to help host and direct the race. Further collaborations there and elsewhere in China are already in development.
For 2016 Mt. Gaoligong Ultra race results and live GPS tracking, click here.
Co-Race Directors Chris Kostman and Lin Ma exchange gifts during the Contract Signing Ceremony at Tengchong City Hall on June 13, 2016.
The race is also featured here on the Badwater website.


text:
Jamshedpur winter festivals 29th Annual flower show ends in grand style
Jamshedpur, December 27, 2017
The 29th Annual Jamshedpur Flower Show hosted by the Horticultural Society of Jamshedpur, with support from Tata Steel and JUSCO, came to a close at Gopal Maidan on Tuesday December 26th
The closing ceremony, saw Dr. Sanjay, principal chief conservator of forests and head of forests force Government of Jharkhand grace the occasion as chief guest and Guest of honor Mr. Sunil Bhaskaran, VP Corporate Services, Tata Steel, who gave the valedictorian speech, and awarded the winners in each category.
Mrs. Madhulika Sharma, President of the Horticultural Society of Jamshedpur, spoke on how gratifying it was to see the record crowd at the show, nearly 30,000 people came to see it on December 25, testifying to the interest this show has garnered from the community, and to see the efforts of the Horticultural Society bearing fruit. Baren Maity, General Secretary of the Horticultural Society, described how the society started with small informal beginnings in 1986, beginning as a small club of devoted local floriculturists who came and put up their first flower show at United Club in 1989, to 335 life members in its 29th year and an ever expanding base of growers who enthusiastically participate every year.
Water conservation was this year's theme, and accordingly, technical sessions and workshops were held for budding and seasoned gardeners to understand this concept, so vital in this age of climate change. Rainwater harvesting was also addressed and there were live models for display for all interested, including models for use by small industrialists. This year's show had another innovation, Aquaponics. This is a combination of hydroponics -- plants primarily growing in water, and aquaculture - the culture of fish. Aquaponics is the concept of plants growing in fish waste, thus creating a recycled ecosystem, and supporting the cause of water conservation. The theme of water conservation was evident in other displays as well. One of the more popular displays was the 'All Time Water Kiosk' popularly referred to as the Water ATM, introduced for the first time; and a 'Nest-in' steel home model from Tata Steel -- all of which were offered as ways to drive home the theme of environmental consciousness, sustainable living, and water conservation. The city's youth participate in large numbers in the technical workshops, especially in the one on water conservation -- as a recognition of the challenge it presents for this generation.
The Flower Show was part of Jamshedpur's Winter Fest, a four-month annual celebration; only on this occasion, it is nature's most beautiful creations that provide the colour and cheer to the winter festivities! Next year's flower show dates were announced -Dec 22 to Dec 25, 2018. A prize distribution ceremony was also conducted for all the winners.
Tata Steel Group is among the top global steel companies with an annual crude steel capacity of 27.5 million tonnes per annum (MTPA) as on March 31, 2017. It is the world's second-most geographically-diversified steel producer, with operations in 26 countries and a commercial presence in over 50 countries. The Group recorded a consolidated turnover of US $18.12 billion (INR 117,420 crore) in FY17. Tata Steel Group is spread across five continents with an employee base of nearly 74,000. Having bagged the Deming Application Prize and Deming Grand Prize for continuous improvement in 2008 and 2012 respectively, Tata Steel has now been recognised as the global 'Industry Leader' in 'Steel category' by Dow Jones Sustainability Index (2015). Besides being a member of the World Steel Climate Action Programme, Tata Steel has also been felicitated with several awards including the Prime Minister's Trophy for the best performing integrated steel plant for 2013-14 (received in 2017), Best Risk Management by CNBC TV18 (2016), 'Best-in-class Manufacturing' award from TIME India (2016) and the 'Most Ethical Company' award from the Ethisphere Institute (2016), IIM Sustainability Award (2015), among several others.

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This multidisciplinary, two-week Institute fosters faculty and program development aimed at enhancing undergraduate teaching and learning about Asian cultures and societies. Hosted annually since 1991, the institute on Infusing Asian Studies into the Undergraduate Curriculum offers undergraduate educators the opportunity to interact with leading Asian studies experts in an intensive program of lectures, discussions, film screenings, site visitsand cultural events.
The 2017 Infusing Institute will be directed by Dr. Peter Hershock and will feature presentations on Chinese history, religion, philosophy, art and literature, as well as sessions on the political economy, social transformation and cultural dynamics of contemporary China.
Designed to meet the needs of educators involved in both curriculum and program development, the Infusing Institute is open both to individual applicants and to two- to three-person teams from colleges and universities committed to furthering undergraduate Asian studies.
Participants will receive lodging in the East-West Center faculty guesthouse and their home institutions are asked to cover airfares and a program fee of $350.


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FreeBookNotes found 5 sites with book summaries or analysis of Faithful Elephants. If there is a Faithful Elephants SparkNotes, Shmoop guide, or Cliff Notes, you can find a link to each study guide below.
Among the summaries and analysis available for Faithful Elephants, there are 1 Short Summary and 4 Book Reviews.
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Our Base hospital in Calicut has all the various Speciality Divisions, which are manned by well qualified and experienced Doctors/Para Medics.
Comtrust Eye Hospital was established in 1999 by the highly respected Comtrust Charitable Trust founded by German Missionaries (Basel Mission), which has an unblemished and uninterrupted history of selfless community service in this part of India for well over 150 years. The Hospital has since been providing top quality Eye Care facilities in the region of North Kerala with Hospitals and vision centres in Calicut, Thallasery, Kodiathur and Wayanad. The charitable activities of the Hospital and its community outreach programs are coordinated by the Comtrust Eye Care Society.
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After the running of the Kentucky Derby and the running of the Preakness Stakes comes the running of the Belmont Stakes, the final jewel in horse racing's Triple Crown.
The Belmont Stakes is the oldest and longest of the three classic horse races, with the Kentucky Derby and the Preakness Stakes, that constitute the Triple Crown of American horse racing.
The Belmont has come to be known as the "Test of the Champion" by horse racing professionals. By the time the race is run, the three-year-old Thoroughbred horses that compete in it have fully matured, and the field of competitors has been weeded out so that only the very best of the crop compete, which is why the field is usually the smallest of the three Triple Crown races.
The Belmont has been run at various distances and tracks in its history. It has been held at Belmont Park, near New York City, and the course has been 1.5 miles (about 2,400 metres) in length since 1926. The race is held early in June and is the final race of the Triple Crown.
Belmont Park is home of the Belmont Stakes, the final jewel of the Triple Crown races. The park has the largest dirt racecourse of any thoroughbred track not only in North America but the world at a mile and a half (2414 m).
A 430-acre racetrack in Elmont, New York, Belmont Park has two race meetings scheduled annually. It is also was the site of the 22nd running of the Breeders' Cup World Thoroughbred Championships on October 29, 2005.
Belmont Stakes has been named the "Run for the Carnations" due to the blanket of white carnation flowers that are draped over the winner's neck. The qualification is 3-year olds and the weight is a Colt/Gelding 126 lbs. and Filly is 121 lbs. The purse for the Belmont Stakes is $1 million.


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Tom Cruise starrer Mission Impossible 7 to resume production amid pandemic, details inside
While the entire entertainment industry was put on halt amid the Coronavirus scare, people have now started to live alongside the deadly viral pandemic. Production for the much-speculated instalment of the blockbuster actioner series, Mission: Impossible, starring Hollywood actor Tom Cruise was halted alongside many other movie productions. However, the latest reports suggest that the makers of the franchise are looking forward to resuming the production of the movie with proper precautions in place.
Production for the seventh instalment to the much-loved franchise was halted earlier this year in wake of the COVID-19, but the makers are in talks to schedule the outdoor shoots primarily in the month of September. Confirming the news, actor Simon Pegg, who plays an important character of Benji Dunn in the franchise, said that they will begin outdoor shooting soon. "That feels fairly doable, and obviously there will be precautions put in place," added the actor.
However, Simon also expressed his uncertainty in the precautionary measures which will be taking place during the production of the actioner. "People that are involved in any close proximity stuff, it will have to be determined that they're safe to do that. I don't know what the testing situation is, how that works, or whether they'll be able to be tested regularly," added the actor.
Mission Impossible 7 was earlier slated to release on 21st of July, 2021, but Paramount Pictures has announced the new release date of the seventh and eighth instalments of the series. Mission Impossible 7 will now hit the screens on November 19, 2021, while the follow-up eighth instalment is scheduled to release on November 4, 2022. Christopher McQuarrie will direct the next two instalments of the franchise starring Tom Cruise as the protagonist.
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You are here Holiday Ideas Travel blogs Hotel shows customer the door after he refuses to show ID — can it do that?
Hotel shows customer the door after he refuses to show ID — can it do that?
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When I was asked for and declined to show ID, a manager who was contacted by telephone spoke with me and refused me admittance unless I showed ID. I offered to pay cash for the room, to avoid suspicion of credit-card fraud, but this was still unacceptable.
The manager then refused to authorize cancellation of my reservation. After I left, my credit card was charged for one night's stay. The charge was removed by American Express only after two months.
I asked Sleep Inn about this requirement to show ID. David Peikin, a company spokesman, said the hotel chain doesn't require IDs to be shown by guests.
As a franchisor, we don't own or operate any hotels. So while we don't have any rules or regulations that require a hotel to request identification, these are independently owned and operated businesses that make their own operational decisions.
Cataldo did a little research to find out if the hotel was within its rights to require an ID.
Continue reading on www.elliott.org
Christopher Elliott has been called one of the world's leading travel experts. But his focus isn't on the destination, or ev…
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Subway set to treble its non-traditional network
The Subway chain has announced that 3,000 jobs will be created in the next five years as part of its plans to treble the number of non-traditional outlets across the UK and Ireland.
Currently the chain has more than 1,500 stores in the UK and Ireland, with more than 150 Subway outlets in non-traditional sites including petrol stations, airports, bus and railway stations, business centres, convenience stores, cinemas, colleges, universities, department stores, motorway service stations, hotels, internet cafes, stadia and military bases.
Trevor Haynes, area development agent for the Subway chain in the UK and Ireland, said: "Non-traditional Subway outlets come in all shapes and sizes and can be found just about anywhere. The simple operations, alongside minimal space and equipment requirements, means that our stores are uniquely suited for non-traditional sites. This form of growth will be an integral part of the chain's development, overall expansion and on-going strategy over the next five years in the UK and Ireland."
Fuel price plunge bottoming out
Certas Energy company owned sites join BOSS
Government presses on with Sunday Trading change
Welcome Break adopts National Living Wage
Service station provides village post office


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Showing all 133 company credits
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APU Productions (international logistics)
APU Productions (international production liaison)
Armytrucks (military vehicles)
Art Resource (courtesy of: stock photos)
Artists Rights Society (copyright owner: Daniel Vazquez Diaz, "Francisco Pizarro, Spanish Conqueror" ©2008) (as Artists Rights Society [ARS], New York)
Big Island Film Commission (the producers wish to thank the following)
Casting Associates (extras casting)
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Dr. Pepper Museum (courtesy of: Dr Pepper items) (as Dr Pepper Museum)
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Free Enterprise Institute (courtesy of: Dr Pepper items)
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Sony Scoring Stage (music recorded at)
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THX Ltd. (digital mastering: 2008 DVD & BD, 2012 BD)
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V & J Translations (Russian translation for tank)
WGBH (courtesy of: "Secrets of a Master Builder" footage) (as WGBH Boston)
Warner Bros. Entertainment (licensed by: "The Wrong Man" poster) (as Warner Bros. Entertainment, Inc.)
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Q: How do you get sudo access for a file inside the vi text editor? Often while editing config files, I'll open one with vi and then when I go to save it realize that I didn't type
sudo vi filename

Is there any way to give vi sudo privileges to save the file? I seem to recall seeing something about this while looking up some stuff about vi a while ago, but now I can't find it.

A: Ryan's advice is generally good, however, if following step 3, don't move the temporary file; it'll have the wrong ownership and permissions. Instead, sudoedit the correct file and read in the contents (using :r or the like) of the temporary file.
If following step 2, use :w! to force the file to be written.

A: In general, you can't change the effective user id of the vi process, but you can do this:
:w !sudo tee myfile

A: % is replaced with the current file name, thus you can use:
:w !sudo tee %

(vim will detect that the file has been changed and ask whether you want to it to be reloaded. Say yes by choosing [L] rather than OK.)
As a shortcut, you can define your own command. Put the following in your .vimrc:
command W w !sudo tee % >/dev/null

With the above you can type :W<Enter> to save the file. Since I wrote this, I have found a nicer way (in my opinion) to do this:
cmap w!! w !sudo tee >/dev/null %

This way you can type :w!! and it will be expanded to the full command line, leaving the cursor at the end, so you can replace the % with a file name of your own, if you like.

A: When you go into insert mode on a file you need sudo access to edit, you get a status message saying
-- INSERT -- W10: Warning: Changing a readonly file

If I miss that, generally I do
:w ~/edited_blah.tmp
:q

..then..
sudo "cat edited_blah.tmp > /etc/blah"

..or..
sudo mv edited_blah.tmp /etc/blah

There's probably a less roundabout way to do it, but it works.

A: Common Caveats
The most common method of getting around the read-only file problem is to open a pipe to current file as the super-user using an implementation of sudo tee.  However, all of the most popular solutions that I have found around the Internet have a combination of a several potential caveats:

*

*The entire file gets written to the terminal, as well as the file.  This can be slow for large files, especially over slow network connections.

*The file loses its modes and similar attributes.

*File paths with unusual characters or spaces might not be handled correctly.

Solutions
To get around all of these issues, you can use the following command:
" On POSIX (Linux/Mac/BSD):
:silent execute 'write !sudo tee ' . shellescape(@%, 1) . ' >/dev/null'

" Depending on the implementation, you might need this on Windows:
:silent execute 'write !sudo tee ' . shellescape(@%, 1) . ' >NUL'

These can be shortened, respectfully:
:sil exec 'w !sudo tee ' . shellescape(@%, 1) . ' >/dev/null'
:sil exec 'w !sudo tee ' . shellescape(@%, 1) . ' >NUL'

Explanation
: begins the command; you will need to type this character in normal mode to start entering a command.  It should be omitted in scripts.
sil[ent] suppresses output from the command.  In this case, we want to stop the Press any key to continue-like prompt that appears after running the :! command.
exec[ute] executes a string as a command.  We can't just run :write because it won't process the necessary function call.
! represents the :! command: the only command that :write accepts.  Normally, :write accepts a file path to which to write.  :! on its own runs a command in a shell (for example, using bash -c).  With :write, it will run the command in the shell, and then write the entire file to stdin.
sudo should be obvious, since that's why you're here.  Run the command as the super-user.  There's plenty of information around the 'net about how that works.
tee pipes stdin to the given file.  :write will write to stdin, then the super-user tee will receive the file contents and write the file.  It won't create a new file--just overwrite the contents--so file modes and attributes will be preserved.
shellescape() escapes special characters in the given file path as appropriate for the current shell.  With just one parameter, it would typically just enclose the path in quotes as necessary.  Since we're sending to a full shell command line, we'll want to pass a non-zero value as the second argument to enable backslash-escaping of other special characters that might otherwise trip up the shell.
@% reads the contents of the % register, which contains the current buffer's file name.  It's not necessarily an absolute path, so ensure that you haven't changed the current directory.  In some solutions, you will see the commercial-at symbol omitted.  Depending on the location, % is a valid expression, and has the same effect as reading the % register.  Nested inside another expression the shortcut is generally disallowed, however: such as in this case.
>NUL and >/dev/null redirect stdout to the platform's null device.  Even though we've silenced the command, we don't want all of the overhead associated with piping stdin back to vim--best to dump it as early as possible.  NUL is the null device on DOS, MS-DOS, and Windows, not a valid file.  As of Windows 8 redirections to NUL don't result in a file named NUL being written.  Try creating a file on your desktop named NUL, with or without a file extension: you will be unable to do so.  (There are several other device names in Windows that might be worth getting to know.)
~/.vimrc
Platform-Dependent
Of course, you still don't want to memorize those and type them out each time.  It's much easier to map the appropriate command to a simpler user command.  To do this on POSIX, you could add the following line to your ~/.vimrc file, creating it if it doesn't already exist:
command W silent execute 'write !sudo tee ' . shellescape(@%, 1) . ' >/dev/null'

This will allow you to type the :W (case-sensitive) command to write the current file with super-user permissions--much easier.
Platform-Independent
I use a platform-independent ~/.vimrc file that synchronizes across computers, so I added multi-platform functionality to mine.  Here's a ~/.vimrc with only the relevant settings:
#!vim
" Use za (not a command; the keys) in normal mode to toggle a fold.
" META_COMMENT Modeline Definition: {{{1
" vim: ts=4 sw=4 sr sts=4 fdm=marker ff=unix fenc=utf-8
"   ts:     Actual tab character stops.
"   sw:     Indentation commands shift by this much.
"   sr:     Round existing indentation when using shift commands.
"   sts:    Virtual tab stops while using tab key.
"   fdm:    Folds are manually defined in file syntax.
"   ff:     Line endings should always be <NL> (line feed #09).
"   fenc:   Should always be UTF-8; #! must be first bytes, so no BOM.

" General Commands: User Ex commands. {{{1
    command W call WriteAsSuperUser(@%)         " Write file as super-user.

" Helper Functions: Used by user Ex commands. {{{1
    function GetNullDevice() " Gets the path to the null device. {{{2
        if filewritable('/dev/null')
            return '/dev/null'
        else
            return 'NUL'
        endif
    endfunction

    function WriteAsSuperUser(file) " Write buffer to a:file as the super user (on POSIX, root). {{{2
        exec '%write !sudo tee ' . shellescape(a:file, 1) . ' >' . GetNullDevice()
    endfunction

" }}}1
" EOF

A: If you're using Vim, there is a script available named sudo.vim.  If you find that you've opened a file that you need root access to read, type:e sudo:%Vim replaces the % with the name of the current file, and sudo: instructs the sudo.vim script to take over for reading and writing.

A: A quick Google seems to give this advice:

*

*Don't try to edit if it's read-only.

*You might be able to change the permissions on the file. (Whether or not it will let you save is up to experimentation.)

*If you still edited anyway, save to a temporary file and then move it.

http://ubuntuforums.org/showthread.php?t=782136

A: Here's another one that has appeared since this question was answered, a plugin called SudoEdit which provides SudoRead and SudoWrite functions, which will by default try to use sudo first and su if that fails: http://www.vim.org/scripts/script.php?script_id=2709

A: I have this in my ~/.bashrc:
alias svim='sudo vim'

Now whenever I need to edit a config file I just open it with svim.

A: A quick hack you can consider is doing a chmod on the file you're editing, save with vim, and then chmod back to what the file was originally.
ls -l test.file (to see the permissions of the file)
chmod 777 test.file
[This is where you save in vim]
chmod xxx test.file (restore the permissions you found in the first step)

Of course I don't recommend this approach in a system where you're worried about security, as for a few seconds anyone can read/change the file without you realizing.

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